Falls are common in older persons. A fall injury is costly in terms of morbidity, loss of physical function and independence, and mortality, as well as health care utilization. Falls have not always been recognized as a serious health problem. Prior to the 1940s, a fall was considered an unpredictable event that could not be prevented. In the past 20 years, however, research studies have shown the incidence and consequences of falls, revealed their multifactorial etiology, and demonstrated that they can be prevented by treating the factors that increase an older person's risk of falling. Effective treatment requires a multidisciplinary approach. Perhaps because of this, fall prevention is not widely practiced in clinical settings outside of specialized geriatric assessment clinics; thus, falls remain an undertreated public health issue.
This chapter addresses nonsyncopal (Syncope is discussed in Chapter 57) falls—unintentional events in which a person comes to rest on the floor or ground that are not caused by loss of consciousness, stroke, seizure, or overwhelming force. Falls in three different settings—the community, skilled nursing facilities, and hospitals—are discussed; reasons for falling and, therefore, interventions differ by site.
Incidence and Prevalence of Falling
Approximately 35% to 40% of persons age 65 years and over fall in a given year; half of persons who fall do so more than once. The incidence increases steadily after age 60 years; approximately 50% of persons aged 80 years and older fall in a year. Women are more likely to fall than men. More than half of all falls in the community happen at home. The rates for falls in skilled nursing facilities and hospitals are almost three times that for community-dwelling elders, and are estimated at 1.5 falls per bed per year.
Incidence of Fall Injuries
Although young children and athletes also have a high incidence of falls, older persons are at high risk of injury with a fall because of age-related changes such as slow reaction time, impaired protective responses, and comorbid diseases such as osteoporosis. As a result, serious fall injuries, including fractures, lacerations, serious soft-tissue injuries, and head trauma, occur in 5% to 15% of falls in the community. Injury rates are higher, from 10% to 25% of falls, in institutional settings. Approximately 8% of persons aged 65 years and older visit an emergency department because of a fall-related injury each year; almost half of these persons are admitted to the hospital for treatment. In 2003, 1.8 million older persons were treated in an emergency department for nonfatal fall injuries. Fractures, most commonly of the hip, pelvis, femur, vertebrae, humerus, hand, forearm, leg, or ankle, occur in approximately 3% of falls. Conversely, falls account for 87% of all fractures and for more than 95% of hip fractures in this group. Falls are the second leading cause of brain and spinal cord injury in older adults. According ...